Provider Demographics
NPI:1932221462
Name:MENCHACA-DURETTE, MARYANN (LVN, RRW)
Entity Type:Individual
Prefix:MRS
First Name:MARYANN
Middle Name:
Last Name:MENCHACA-DURETTE
Suffix:
Gender:F
Credentials:LVN, RRW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 PASEO ENTRADA
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6723
Mailing Address - Country:US
Mailing Address - Phone:619-421-2239
Mailing Address - Fax:
Practice Address - Street 1:234 N MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-3906
Practice Address - Country:US
Practice Address - Phone:619-579-8373
Practice Address - Fax:619-579-8155
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37-09101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)